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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# )SERVICE REQUEST# <br /> Convenient Store with Gas <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Makhan Singh Ni"ar and Gurinder Singh ❑ <br /> FACILITY NAME <br /> Quik Stop Market#551120 <br /> SITE ADDRESS Stockton 95209 <br /> 9321 N.. Thornton Rd. <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 165 Flanders Rd., Flanders Rd. <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Westborough MA 01581 <br /> PHONE#1 E"T APN# o�V!I U LAND USE APPLICATION# <br /> ( 508 ) 270-4401 0801 50000 U <br /> PHONE#2 Exr. BOS DISTRIC�� LOCATION COPE <br /> ( 9251 336-1596 2) 0 t <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Vicky Cassell CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEQuik Stop Markets, Inc. ( 925 336-1596 E><r <br /> HOME Or MAILING ADDRESS FAX# <br /> 38995 Farwell Dr. ( ) <br /> CITY Fremont STATE CA ZIP 94536 <br /> BILLI ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL flaws. <br /> �� <br /> APPLICANT'S SIGNATURE: (te� 4�� DATE: 07/08/2021 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Franchise Manager <br /> If APPLICANT is not the BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment%IMEp1$nent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t,ve-w fapit is <br /> provided to me or my representative. ' <br /> TYPE OF SERVICE REQUESTED: / <br /> JUL <br /> �a1119ONMEMA11 <br /> Retail Markel 2,200 SQ/FT with Food Prep HENLTHOEPmaraEsr <br /> ACCEPTED BY: C[Cffu GS co EMPLOYEE#: DATE: $r- 2( <br /> ASSIGNED TO: EMPLOYEE#: DATEf7—�- 74 <br /> Date Service Completed (if already completed): SERVICE CODE: © PIE: <br /> Fee Amount. I✓r Amount Paid 2, Payment Date v <br /> Payment Type VL, Invoice# Ghee k i4 $2 Receive By: <br /> EHD 48-02-025 T ` �Z) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />